Elderly Denture Wearers Research Articles

Effect of ageing and tooth loss on sensory function of alveolar mucosa.

Maintaining quality of life of elderly denture wearers is one of the most crucial tasks for dentists in the super-aged society. Although external mechanical load on removable dentures has been investigated to minimise a risk of soreness caused by dentures, sensory perception of the alveolar mucosa remains obscure. This study aimed to investigate effect of ageing and tooth loss in sensory function on the alveolar mucosa for deep understanding of the characteristics of pain sensitivity in edentulous individuals. Eighteen edentulous participants (ED), as well as 18 age-matched dentate participants (EC) and 18 young dentate participants (YC), participated in this study. Tactile detection threshold (TDT) and pain threshold (PT) were measured with von Frey filaments (0.125-512mN). Mechanical pain sensitivity (MPS) after a 2-sec application of 1kg palpation was assessed with a 0-50-100Numerical Rating Scale (NRS) (0: no pain, 50: slight pain and 100: the worst pain imaginable). Furthermore, entropy scores of TDT, PT and NRS on MPS were calculated. In both maxilla and mandible, EC showed significantly higher TDT and PT, compared with YC, whereas ED showed significantly lower TDT and PT, compared with EC. NRS on MPS in ED was significantly higher than that in EC. The entropy scores of all the outcome parameters showed no significant difference between groups. Both ageing and tooth loss can alter tactile and pain perception in the oral mucosa. This suggests that it might be beneficial to assess sensory function of the alveolar mucosa in edentulous patients clinically in prior to denture fabrication.

Analysis of the relevant factors associated with oral health-related quality of life in elderly denture wearers.

The purpose of the present study was to explore the factors related to oral health-related quality of life (OHRQoL) in elderly patients who underwent prosthetic treatment with removable dentures through several objective and subjective examinations and to analyze their interrelationships. The current study involved 78 denture wearers, aged 65 years or above, who underwent treatment at the clinic of prosthodontics and undertook routine checkups. The present study used eight age-matched patients with healthy dentition as controls. The following items were evaluated: OHRQoL (Oral Health Impact Profile), main occluding area, maximal occlusal force, masticatory performance, and masticatory ability. Spearman's rank correlation coefficient was used to assess the correlation between the OHIP score and each item and multiple linear regression analysis with the backward elimination method was used to analyze the factors affecting the OHIP score (α = 0.05). The OHIP summary score was significantly correlated with the number of occlusal supports, number of remaining teeth, maximal occlusal force, and the masticatory ability score. The multiple regression analysis revealed that the number of occlusal supports, the number of remaining upper teeth, whether the upper main occluding area was the remaining tooth or not, and the masticatory ability score were the significant independent variables that affected the OHIP summary scores. The present study verified the relationship between the OHRQoL and the occlusion of remaining teeth or the items derived from the main occluding areas. The current results suggest that retaining the maxillary first molar is a key factor in the OHRQoL.

Clinical and Microbiological Evaluation of the Effect of Heat Killed Lactobacillus Acidophilus and Garlic Extract on Candida Albicans in a Group of Elderly Denture Wearers

Continuous denture wearing, lack of adequate hygiene and infection with Candida albicans (C. albicans) are among the etiological factors of Denture stomatitis (DS). The management of DS ranges from the implementation of oral hygiene measures and removal of predisposing factors to the use of antifungals, depending on the severity of inflammation. Aim of the study: This study aimed to evaluate the short-term effect of heat killed lactobacillus acidophilus - Lacteol Fort® (LF)- as a probiotic and garlic extract -Tomex Plus® (TP)- as a prebiotic on salivary C. albicans counts and biofilm-forming ability, in elderly denture wearers with DS. Methods: This was a single-center, single‐blind, randomized pilot clinical trial. 27 complete denture wearers were randomly allocated into 3 groups; group I (control), group II (LF) and group III (TP). Each group was clinically assessed for DS and microbiologically evaluated for salivary C. albicans counts at baseline and after 15 days. The biofilm-forming ability of salivary C. albicans was assessed, as well, for each group at the end of the experimental period. Results: clinical assessment revealed a reduction in the total erythematous area dimension from 3.00 ± 0.40 mm for group II (LF) and from 3.20 ± 0.54 mm for group III (TP) to ≤2 mm for either group after treatment. Microbiological evaluation showed that C. albicans counts and biofilm-forming ability were significantly lowered in groups II (LF) and III (TP). Conclusion: LF and TP were both found to be effective in reducing DS associated inflammation, C. albicans counts and biofilm-forming ability.

Antibacterial activity of Algerian chewing sticks extracts on oral denture biofilm

Aims and Objectives: To evaluate potent antibiofilm activity of two Algerian chewing sticks, Salvadora persica and Juglans regia, on oral species adhered to elderly dentures. Materials and Methods: The antibacterial activity of the plant extracts and the effect on the biofilm formation were evaluated in vitro by the broth micro-dilution assay. The antibiofilm effect was tested in vitro on artificial oral biofilms, adhered to resin composite, and visualized by environmental scanning electron microscope. Results: Data revealed that bacteria of artificial biofilms were less sensitive than the planktonic strains. However, all tested bacteria, planktonic or biofilms, were more susceptible in the presence of extracts, with J. regia extract showing greater activity than S. persica. Conclusion: All tested oral bacteria, planktonic or biofilm, were more susceptible to J. regia and S. persica, respectively. Considering their antibacterial activity, these extracts may be of great interest for future studies about natural antiplaque agents in daily oral-care products, especially for elderly denture wearers.

To evaluate the effect of probiotics on the prevalence of oral Candida organisms in denture wearers: An in vivo study

STATEMENT OF PROBLEM: Candida species are the major human fungal pathogens that cause both mucosal and deep-tissue infections. Fungal infections have been successfully treated by systemic antifungal agents for a very long time. The toxicity of available antifungals and resistance to these drugs are a concern; thus, the use of probiotics has emerged as an alternative therapeutic technique for treating Candida infections. PURPOSE: The purpose of this study was to evaluate the effect of probiotics on the prevalence of oral Candida organisms in denture wearers with different age groups. MATERIALS AND METHODS: Sixty completely edentulous denture wearers were divided into three groups: 50–59 years (Group A), 60–69 years (Group B), and 70 years and above (Group C). The sample collected from the denture surface and palatal mucosa pre- and postprobiotic usage were subjected to CHROMagar followed by Germ tube test and then Corn meal agar for identification and counting the number of Candida colonies. The attributed scores were tabulated and submitted for statistical analysis using Kruskal–Wallis ANOVA test, Mann–Whitney U-test, Wilcoxon matched pairs test, and paired t-test. RESULTS: Reduction in the number of Candida colonies was statistically significant in Group A and Group B on the denture surface as compared to that of Group C. However, there was no significant difference observed in all the three groups in the number of Candida colonies on the palatal mucosa. CONCLUSION: The study shows that multispecies probiotic product may represent as an alternative treatment for reduction of Candida infections in the oral cavity of elderly denture wearers.

Hydrophilic nano-silica coating agents with platinum and diamond nanoparticles for denture base materials

Preventing microorganisms from adhering to the denture surface is important for ensuring the systemic health of elderly denture wearers. Silica coating agents provide high hydrophilicity but lack durability. This study investigated solutions to improve the durability of the coating layer, determine an appropriate solid content concentration of SiO2 in the silica coating agent, and evaluate the effect of adding platinum (Pt) and diamond nanoparticles (ND) to the agent. Five coating agents were prepared with different SiO2 concentrations with/without Pt and ND additives. The contact angle was measured, and the brush-wear test was performed. Scanning electron microscopy was used to investigate the silica coating layer. The appropriate concentration of SiO2 was found to be 0.5-0.75 wt%. The coating agents with additives showed significantly high hydrophilicity immediately after coating and after the brush-wear test. The coating agents with/without additives formed a durable coating layer even after the brush-wear test.

Decreased production of proinflammatory cytokines by monocytes from individuals presenting Candida-associated denture stomatitis

Candida-associated denture stomatitis (DS) is the most frequent lesion among denture wearers, especially the elderly. DS is strongly associated with Candida albicans, as well as local and systemic factors, such as impaired immune response. Monocytes are important in the protective immune response against the fungus by the production of cytokines that recruit and activate leukocytes. There are functional changes in these cells with age, and individual alterations involving monocyte response may predispose the host to developing infections by Candida spp. In this study, our aim was to evaluate the production of TNF-α, IL-6, CXCL8, IL-1β, MCP-1 and IL-10 by monocytes from elderly denture wearers with/without DS and elderly or young non-denture wearers. We detected that monocytes from elderly denture wearers with Candida-related denture stomatitis produced lower levels of CXCL-8, IL-6 and MCP-1. This imbalance in cytokine levels was observed in spontaneous or LPS-stimulated production. Therefore, our data suggested that inherent aspects of the host, such as changes in cytokine production by monocytes, might be associated with the development and the persistence of DS irrespective of aging.

高齢者の栄養障害に義歯装着がもたらす効果と高齢義歯装着者への摂食・栄養指導のガイドラインに関するプロジェクト研究

高齢者の栄養障害に義歯装着がもたらす効果と高齢義歯装着者への摂食・栄養指導のガイドラインに関するプロジェクト研究

A multispecies probiotic reduces oral Candida colonization in denture wearers.

The prevalence of Candida infections has been rising with an increasingly aging population and a larger population of immunocompromised individuals. The use of probiotics may be an alternative approach to antifungal agents in the prevention and treatment of oral candidiasis. This study aimed to evaluate the short-term effect of probiotics in reducing the infection level of oral Candida in candidiasis-asymptomatic elderly denture wearers. In a double-blind randomized study, 59 denture wearers harboring Candida spp. in the oral cavity with no clinical symptoms were allocated into two groups: probiotic and placebo. All patients were instructed to clean the denture daily. The probiotic group poured a capsule containing lyophilized Lactobacillus rhamnosus HS111, Lactobacillus acidophillus HS101, and Bifidobacterium bifidum daily on the palatal surface of the maxillary denture, whereas the placebo group was submitted to the same regimen using placebo capsules. Candida spp. infection levels were evaluated in palate mucosa samples obtained before and after a 5-week experimental period. All patients harbored Candida in the palate mucosa at baseline. Fifty-five individuals completed the experimental period. The detection rate of Candida spp. was 92.0% in the placebo group after the experimental period, whereas it was reduced to 16.7% in the probiotic group. The reduction promoted by the probiotic regimen was independent of baseline characteristics such as Candida infection level and colonizing species, age of denture, and other variables. The probiotic product was effective in reducing the colonization of the oral cavity with Candida in candidiasis-asymptomatic elderly denture wearers, suggesting that this multispecies probiotic could be used to prevent oral candidiasis. Colonization of oral surfaces by Candida is considered a risk factor for invasive fungal infections. The use of a product with L. rhamnosus, L. acidophilus, and B. bifidum may represent an alternative treatment for reduction of Candida infections in elderly denture wearers.

Risk factors for denture-related oral mucosal lesions in a geriatric population

Denture-related mucosal lesions have been broadly studied. However, no consensus has been reached regarding the risk factors associated with these lesions, and few studies have used multivariable analysis to determine the relative significance of different risks. The purpose of this study was to determine the relationship between systemic, local, and denture factors on the risk of denture-related oral mucosal lesions in an elderly population by using multivariable analysis. Eighty-four elderly denture wearers recruited from geriatric residences and day care centers participated in this cross-sectional study. All data were obtained by means of a questionnaire-interview, a physical examination, and complementary tests. Bivariate relationship and multiple logistic regression analyses were performed (α=.05). Angular cheilitis (34%), traumatic ulcers (15%), and denture stomatitis (14%) were the 3 most common lesions, and the prevalence of at least 1 denture-related mucosal lesion was 54%. The presence of denture stomatitis was related to low saliva pH, never having smoked, and regular sugar consumption. Angular cheilitis was associated with age, complete edentulism, the presence of oral Candida, a lack of denture stability, and a reduced occlusal vertical dimension. The presence of traumatic ulcers was related to a resorbed residual alveolar ridge. The presence of at least 1 lesion was associated with poor masticatory efficiency, being resident in a care facility, oral Candida, and a lack of denture stability. Several systemic, local, and denture-related characteristics are independent risk factors for denture-related mucosal lesions in an elderly population.

Residual ridge resorption, lower denture stability and subjective complaints among edentulous individuals

Residual ridge resorption in the mandible after tooth loss may lead to worsening of complete denture stability and to various subjective complaints. The aim was to evaluate the association between radiologically assessed residual ridge resorption in the mandible, clinically assessed stability of lower complete denture and subjective complaints among elderly denture wearers. The study population consisted of 326 (115 men and 211 women) edentulous subjects aged 60-78years, all of whom were wearing complete dentures in the mandible. Data on subjective complaints were obtained from questionnaires and interviews. Denture stability was assessed clinically. Residual ridge resorption was analysed from panoramic radiographs. The results showed that women were significantly more often satisfied with their lower dentures and reported fewer problems with eating than men. They also had significantly more often residual ridge resorption than men. Among women, residual ridge resorption was significantly associated with poor chewing ability, low satisfaction with dentures and poor denture stability. Among men, residual ridge resorption did not associate with subjective complaints or denture stability. Poor satisfaction with dentures associated significantly with poor denture stability in both genders. In conclusion, these results highlight the importance of denture maintenance treatment. As the extent of residual ridge resorption in the mandible was the most important factor that increased dissatisfaction with lower complete dentures, it is also important to inhibit the progression of resorption by preventing tooth loss or by using implant-retained dentures.

Nocturnal masseter electromyographic activity of complete denture wearers

Collection of normative data on activity patterns of the masseter during sleep in elderly denture wearers by portable electromyography (EMG) recorders. Complete denture wearers might suffer from orofacial pain caused by myoarthropathies of the masticatory system. Indeed, denture instability may precipitate parafunctional habits and consequently muscle soreness and/or temporomandibular pain. We collected normative masseter EMG data during sleep in 15 complete denture wearers (five women, 10 men, 56-88 years) by portable recorders in their natural environment. Activity periods (AP) were signal portions including subthreshold intervals ≤5 s. Signal amplitude was expressed in per cent of maximum voluntary contraction (%MVC). For this reason, maximum bite force was assessed. Twenty age-matched dentate controls were also recorded for the maximum bite force. We found 157.2 ± 86.5 AP per night, i.e. 24.0 ± 12.2 AP/h. Mean amplitude was 15.1 ± 4.3%MVC. AP lasted 6.8 ± 4.1 s, and their time integral was 126.3 ± 112.5%MVC•s. Maximum bite force was 116.8 ± 69.6 N in the edentulous, significantly lower than in controls (344.8 ± 150.4 N). Healthy complete denture wearers showed intermittent periods of nocturnal masseter activity of very low intensity and short duration.

Differences between salivary and blood neutrophils from elderly and young denture wearers

We previously showed that neutrophils from patients with Candida-related denture stomatitis exhibited damaged function, and the advance in age intensified this condition. Because such alterations had been determined in elderly people that were not denture wearers, the purpose of this study was to clarify functional and phenotypic characteristics of neutrophils from elderly denture wearers (EDW) and young denture wearers (YDW) without oral lesion. We enrolled 20 denture wearers (12 EDW and 8 YDW) and determined the positivity of Candida species on maxillary prosthesis and palate. Additionally, blood and salivary neutrophils were evaluated. Furthermore, cytokines and chemokines salivary levels were detected. YDW presented higher positivity of Candida albicans than elderly ones. However, blood neutrophils from EDW expressed less CXCR1, CD62L and CD11b and had lower C. albicans phagocytosis than YDW. Although myeloperoxidase and elastase activity was significantly higher in C. albicans-stimulated blood neutrophils from elderly, they produced high levels of IL-10 and low levels of Granulocyte macrophage-colony stimulating factor (GM-CSF). Despite apoptosis rate of salivary neutrophils was enhanced, these cells were at a high number in YDW. GM-CSF and IL10 were lower in saliva from elderly group. These data confirmed that ageing affects blood and salivary neutrophils and could predispose elderly to persistent oral infections.

Influence of denture treatment on brain function activity

Summary The objective of the present study was to clarify whether the treatment of complete dentures and the use of partial dentures influence brain function activity as determined by electroencephalograms (EEG). Eighteen complete and twenty partial denture wearers participated in the study. In order to evaluate denture function, the occlusal contact area and occlusal force were measured using a Dental Prescale Occluzer ® . To evaluate brain function activity, EEG data obtained employing ESA-pro were analyzed using DIMENSION. The occlusal contact area significantly increased after complete denture treatment in all 18 subjects and significantly increased with wearing partial dentures in all 20 subjects. The occlusal force of complete and partial denture subjects significantly increased. An increase in brain function activity was noted in 14 of the 18 complete denture wearers, and after gum chewing with dentures in the 20 partial denture wearers. In this study, it was revealed that brain function activity was enhanced by the improvement of complete dentures, and by wearing partial dentures. Not only denture function improvement but also brain functional activation was achieved in elderly denture wearers at risk of brain activity deterioration.

Biofilm formation of Candida albicans on the surface of a soft denture‐lining material

Soft denture lining-materials are more susceptible to microbial adhesion than hard denture base acrylic resin. Poor oral hygiene and Candida albicans infection are common among elderly denture wearers as these patients usually have difficulty in keeping them clean. To evaluate the influence of the oral hygiene methods on the formation of a biofilm over a soft denture-lining material. Twenty volunteers were randomly separated into two groups: G1 and G2. Ten volunteers performed daily hygiene of the prostheses with a soft toothbrush and toothpaste. The G2 performed a treatment identical to G1 but also immersed the prostheses in sodium hypochlorite 0.5% for 20 min, once a week. Quantification of the mean score values of biofilm formation at different times were statistically analysed using analysis of variance and Tukey's test (alpha = 0.05). G1 (0.65 +/- 0.52) showed the lowest mean score values of biofilm formation. There was statistical difference between G1 and G2. The highest mean score values were found at 6 weeks (1.3 +/- 1.08) and were statistically different from other times. The oral hygiene methods had a significant effect in the formation of the biofilm over a soft denture-lining material.

Ageing exacerbates damage of systemic and salivary neutrophils from patients presenting Candida-related denture stomatitis

BackgroundAgeing leads to a decline in the function of the immune system, increasing the body's susceptibility to infections through the impairment of T-cells, macrophages, neutrophils and dendritic cells Denture stomatitis is a primary oral disease affecting elderly denture wearers. The major etiologic factor involved in this pathology is the infection by Candida albicans, an opportunistic pathogen that causes local and disseminated diseases in immunosuppressed humans. Neutrophils play a critical role in the immune response against C. albicans and are continually present in the salivary fluid and in the blood. The aim of this study was to determine ageing-related changes in salivary and blood neutrophils and their potential implications in Candida-related denture stomatitis.ResultsOur results showed a lower number of neutrophils in the saliva from patients presenting Candida-related denture stomatitis in comparison to their matched controls. Furthermore, fewer neutrophils were isolated from the saliva of aged control individuals in comparison to matched younger subjects. CXCR1, CD62L and CD11b expression were significantly greater on systemic neutrophils from younger control individuals. Elderly individuals showed more apoptotic salivary neutrophils and lower GM-CSF levels than younger ones, regardless of the occurrence of Candida infection. On the other hand, CXCL-8 concentrations were higher in the saliva from elderly individuals. Besides, TNF-α was detected at elevated levels in the saliva from infected elderly subjects. Salivary neutrophils from elderly and young patients presented impaired phagocytic activity against C. albicans. However, just systemic neutrophils from elderly showed decreased phagocytosis when compared to the younger ones, regardless of the occurrence of infection. In addition, neutrophils from aged individuals and young patients presented low fungicidal activity.ConclusionThe data suggests that the Candida related-denture stomatitis is associated to neutrophils function deficiency, and ageing drastically appears to alter important characteristics of such cells, facilitating the establishment of this infection.

Factors Affecting the Satisfaction of Elderly Denture Wearers

目的：自立して社会生活を送る一般的な高齢者の義歯に対する主観的評価と「咬めること」，「食事中に外れないこと」，「痛くないこと」の3要因ならびに歯の欠損形態，咀嚼可能な食品との関連を明らかにすることを目的とした．方法：対象は，平成19年度厚生科学研究「口腔保健と全身的な健康状態の関係について」の調査に参加した，新潟市在住で義歯を装着している79～80歳の256名とした．義歯の満足度と「咬めること」，「外れにくいこと」，「痛みがないこと」についてVAS値でアンケートを行った．さらに，欠損形態を宮地分類でグループ化し，義歯満足度との関連を調べた．また，15品目の食品が咀嚼可能かを調べた．結果：義歯の満足度は，「咬めること」，「外れにくいこと」，「痛みがないこと」との間に相関があったが，一つの項目のみが突出して高い関連を示すことはなかった．宮地分類と義歯に対する満足度との間に，関連は認められなかった．義歯の満足度（VAS値）により分けた4群間では，不良群で咬める食品数が有意に低かった．結論：義歯の満足度を高めるには，咬めて，外れにくく，使用時に痛みのないことが必要であることが確認された．一方，今回の調査からは義歯の満足度と宮地分類との間には関連が認められなかった．これは，難しい欠損形態でも義歯の製作や調整次第で，満足が得られる可能性を示唆すると考えられた．

Oral candidosis, denture cleanliness and hygiene habits in an elderly population

Poor denture hygiene and Candida infections are very common among elderly denture wearers. Candida species are usually innocuous, but they can cause disease when conditions are favorable. Oral hygiene habits have been found to be poor among the elderly. This may be due to decreasing manual abilities due to advanced age. Dentures act as a reservoir for yeasts, and this may be aggravated by poorly fitting and old dentures. The purpose of this study was to determine oral hygiene habits, denture cleanliness and presence of yeasts in elderly complete denture wearers. 42 subjects who had worn complete upper dentures for at least six months were surveyed. The mean age of the subjects was 74 years. Information about denture age, denture hygiene and hygiene habits of subjects was obtained through a structured interview. Clinical examination was conducted by one author. Denture cleanliness was assessed by using the Schubert and Schubert index. For cytological examination, palatal swabs were taken. A chi-square test was used to analyze the results. A significant correlation was seen between oral candidosis and frequency of denture cleaning, and also between candidosis and denture cleanliness. There was no statistically significant correlation between denture cleaning methods and candidosis. The relationship between denture age and the presence of Candida was not significant. There was a significant correlation between denture cleanliness and denture age, cleaning method or frequency of cleaning. Only 16.7% of dentures worn by the elderly are properly cleaned. Older dentures tended to be dirtier than newer ones. There was a significant correlation between poor denture hygiene and prevalence of Candida.

Validation of communication between elderly denture wearers and dentists: a questionnaire on satisfaction with complete dentures using semi‐structured interviews

To validate a semi-structured interview (SSI) for communication between complete denture wearers and dentists. A SSI using a questionnaire with eight questions on satisfaction with complete dentures (CD): covering function, aesthetics and comfort. The first seven questions used a five-point Likert scale and the last was dichotomous. Two dentists, carefully trained in the use of the structured questionnaire, administered the SSI. A Greek Department of Prosthetic Dentistry. A consecutive sample of 78 CD wearers took part in the study. All subjects presented with complaints from their dentures. All participants and their dentures underwent clinical examination. The method showed good reliability, verified by the Cronbach alpha (0.86). Both dentists used the questionnaire produced very similar results. (Wilcoxon test 61-99%). Further, the association of the answers with respect to the five-point Likert scale was very high; all gamma coefficients were statistically significant except for pain and discomfort from the upper CD (CDU). This method of communication between patients and dentists is reliable and can be used to give good repeatability for qualitatively assessing satisfaction with CD. It can be valuable for clinical use and for extending the study of denture quality to establish outcome measures based on the subjective criteria of satisfaction.

Impact of Human Genome Project on treatment of frail and edentulous patients.

Because of ongoing increases in life expectancy and deferment of edentulousness to older age, dentists are facing a different challenge to satisfy elderly denture wearers with a higher prevalence of chronic diseases. This discussion introduces the Human Genome databases as novel and powerful resources to re-examine the core problems experienced by frail and edentulous patients. Recent studies demonstrated that mandibular implant overdentures do not necessarily increase masticatory function, perception and satisfaction in denture wearers with adequate edentulous residual ridges. It has been demonstrated that the rate of edentulous residual ridge resorption significantly varies among individuals. The prognosis and cost-effectiveness of denture treatment, with or without implants, may largely depend on how the edentulous ridge is maintained. However, reliable clinical methods permitting dentists to predict the long-term health of the edentulous residual ridge are lacking. With the completion of the Human Genome Project, the genomic sequence database from this multinational consortium will provide a unique resource to determine the genetic basis of similarity and diversity of humans. One base pair in every 100 to 300 base pairs of the genome sequence varies among humans, suggesting that genetic diagnosis using the single nucleotide polymorphisms (SNPs) may provide a novel opportunity to differentiate our edentulous patients. Future dental service for the elderly will require a personalized care paradigm, using highly sensitive diagnostic technology such as SNP genomic analysis, for recommending the treatment with greatest potential benefit.